Patient information: Bloody stools in children

INTRODUCTION

Seeing blood on your child's stool can be frightening. However, this is a common condition in children and is usually not serious. There are many possible causes of bloody stools, with the most likely cause depending upon your child's age. A healthcare provider can help to determine the source of the bleeding and the most appropriate treatment.

This article will review some of the common causes of bloody stools and tests that may be used to evaluate your child. Bloody stools in adults is discussed separately. (See "Patient information: Blood in the stool (rectal bleeding) in adults".)

WHEN TO SEEK HELP

Most children with minor rectal bleeding do not have a serious condition. However, it is not possible to know the cause of rectal bleeding without an examination. Thus, if you notice that your child has rectal bleeding, you should talk to your child's healthcare provider to determine if an examination is needed. (See 'Rectal bleeding tests' below.)

TYPES OF RECTAL BLEEDING

There are two possible sources of bloody stools: the upper digestive tract (stomach and small intestine) and the lower digestive tract (the colon, rectum, and anus).

• Bleeding from the upper digestive tract usually causes black, tarry stools.
• Bleeding from the lower digestive tract usually causes the stool to be coated or mixed with bright red blood.
• Certain foods and medications can also cause the stool to appear bloody. A list of these foods and medications is provided in table 1 (table 1).

However, it is not always possible to know the source or type of rectal bleeding based upon the appearance of the stool alone. An evaluation and physical examination is necessary in most cases. (See "Approach to lower gastrointestinal bleeding in children".)

RECTAL BLEEDING CAUSES

Anal fissure — An anal fissure is a tear or crack in the anus that can develop when an infant or child passes a large or hard stool. Anal fissures can occur in all age groups, from newborns to school-aged children and even adults. (See "Patient information: Anal fissure".) The symptoms of an anal fissure include pain, straining or grunting during a bowel movement, and bright red blood on the outside of the stool or with wiping.

Many infants and children with anal fissures also have a history of constipation or fairly hard stools. Treatment of constipation is discussed separately. (See "Patient information: Constipation in infants and children".)

Milk or soy protein intolerance — Milk or soy protein intolerance, also known as milk allergy, milk-induced enterocolitis, or protein-induced proctitis or proctocolitis, is a condition that can develop in infants. It is caused by a sensitivity to the protein in cow's milk or soy, and usually develops after starting formula. It can also occur in infants who breastfeed as a result of cow's milk or soy products consumed by the mother. The protein intolerance usually resolves by one year of age.

Symptoms of milk or soy protein intolerance may include vomiting and diarrhea, in addition to blood-tinged or bloody stools. If milk or soy protein intolerance seems to be the most likely cause after an evaluation by the medical provider, a milk-free diet is often prescribed. This is described in a separate article. (See "Patient information: Gastroesophageal reflux in infants", section on 'Milk-free diet'.)

Less common causes

• Inflammatory bowel disease, also known as Crohn's disease or ulcerative colitis, is a condition in which the lining of the bowels become inflamed. The inflammation leads to symptoms, such as bloody stools, diarrhea, lack of appetite, and weight loss. Crohn's disease and ulcerative colitis are discussed in more detail in a separate article. (See "Clinical manifestations of Crohn's disease in children and adolescents" and "Ulcerative colitis in children and adolescents".)

• Infectious diarrhea is diarrhea caused by a virus, bacterium, or parasite that can cause bloody stools in preschool and school-aged children. Infectious diarrhea can develop as a result of eating or drinking contaminated foods/drinks, or less commonly, after taking a course of antibiotics. (See "Patient information: Food poisoning (food-borne illness)" and "Patient information: Antibiotic-associated diarrhea (Clostridium difficile)".)

Symptoms of infectious diarrhea usually include bloody diarrhea, fever, and abdominal pain. Treatment of diarrhea in children is discussed separately. (See "Patient information: Acute diarrhea in children".)

• Juvenile polyps are growths that can develop between the ages of two and eight years. Symptoms usually include painless rectal bleeding. Juvenile polyps are not usually cancerous or pre-cancerous but should be evaluated by a healthcare provider and usually require removal.
• A number of other, more serious conditions, including intussusception (a form of bowel obstruction) or Hirschprung's disease (a form of colon obstruction that develops before birth) can also cause rectal bleeding. Obstruction is the medical term for a blockage in the bowels. Most of these conditions cause the infant or child to become ill suddenly. If your child suddenly develops bloody stools and becomes lethargic, has abdominal pain, fever, or other unusual symptoms, call your child's healthcare provider immediately. (See "Intussusception in children" and "Congenital aganglionic megacolon (Hirschsprung disease)".)

RECTAL BLEEDING TESTS

Sometimes a clinician can determine the cause of the bleeding by inspecting the outside of the anus. This may include a brief examination of the inside of the anus using a finger (rectal examination). The clinician can also test a sample of stool to be sure whether or not it contains blood.

This examination may be all that is necessary. If the cause of the bleeding is not clear based upon the examination, further testing may be recommended.

RECTAL BLEEDING TREATMENT

As discussed above, there are a number of potential causes of bloody stools. Your child's healthcare provider will determine if the underlying condition requires treatment. Even if your child's bleeding seems minor or resolves on its own, your child should be evaluated by a healthcare provider.

WHERE TO GET MORE INFORMATION

Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Blood in the stool (rectal bleeding) in adults
Patient information: Anal fissure
Patient information: Constipation in infants and children
Patient information: Gastroesophageal reflux in infants
Patient information: Food poisoning (food-borne illness)
Patient information: Antibiotic-associated diarrhea (Clostridium difficile)
Patient information: Acute diarrhea in children

Professional Level Information:
Approach to lower gastrointestinal bleeding in children
Clinical features and diagnosis of necrotizing enterocolitis in newborns
Diagnosis of inflammatory bowel disease in children and adolescents
Dietary protein-induced proctitis/colitis, enteropathy, and enterocolitis of infancy
Management of necrotizing enterocolitis in newborns
Clinical manifestations of Crohn's disease in children and adolescents
Ulcerative colitis in children and adolescents
Intussusception in children
Congenital aganglionic megacolon (Hirschsprung disease)

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/ency/article/003130.htm)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (http://digestive.niddk.nih.gov/ddiseases/pubs/constipationchild/)

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